LPN INTENSIVE CLINICALS�� CHAPTER 5 - INFECTIONS��� INTENSIVE GPHC Exam revision � programme FOR NOV 2025

LONDON PHARMACIST NETWORK (LPN)

INTENSIVE REVISION FOR NOV 2025

GPHC EXAM.

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INTRODUCTION

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• After completing the relevant work on this topic, you should be able to -
• Learn relevant NICE guidelines on anti-microbial prescribing.
• Learn important examples of notifiable diseases.
• Learn to spot crucial drug interactions AND their effects on patients.
• Prophylaxis and therapy using antibiotics
• Key points on major examples of antibiotics
• Anti-fungal, anti-viral and HIV treatment
• Learn relevant cautionary labels.
• Remember important and common side-effects.
• Learn advice to be given to patients and when to refer.
• KNOWLEDGE APPLICATION OF KEY INFORMATION IN CHAPTER 5

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NEW BNF UPDATES IN CHAPTER 5 - 2025

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• SEPSIS MANAGEMENT
• Urinary-tract infections: updated guidance for the prophylaxis of recurrent urinary tract infections.
• Lower urinary tract symptoms in males: new guidance
• Antibacterial, use for prophylaxis: updated guidance on secondary prevention of meningococcal disease and secondary prevention of pertussis.
• Co-amoxiclav: update to structure of indications and dose section; tablet dose expression changed to co-amoxiclav (total of amoxicillin and clavulanic acid).

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NEW BNF UPDATES IN CHAPTER 5 - 2025

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• Nitrofurantoin: reminder of the risks of pulmonary and hepatic adverse drug reactions [MHRA/CHM advice]. NEW Renal function guidance.
• INFLUENZA VACCINE: UPDATED GUIDANCE FOR IMMUNISATION.
• MALARIA PROPHYLAXIS: UPDATED GUIDANCE.
• Quinolones: reminder of the risk of disabling and potentially long-lasting or irreversible side effects [MHRA/CHM advice] (see example in ciprofloxacin). Fluoroquinolone. AORTIC ANEURISYMS
• Quinolones: suicidal thoughts and behavior [MHRA/CHM advice] (see example in ciprofloxacin). Fluoroquinolone
• PHARMACY FIRST SCHEME !!! 7 CONDITIONS

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CAUSATIVE MICRO-ORGANISMS

QUESTION

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• You work as a hospital pharmacist. An elderly patient is given a course of antibiotics to treat an infection.
• Unfortunately, he suffered an adverse drug reaction. Lab tests show elevated liver enzymes ALT/AST >2 X ULN and total bilirubin > 3 x ULN.

Which antibiotic medication is mostly responsible for this?

1. Clarithromycin
2. Trimethoprim
3. Flucloxacillin
4. Ciprofloxacin
5. Amoxicillin

NOTIFIABLE DISEASES

ANTIBIOTICS IN PREGNANCY

QUICK POINTS - MHRA ADVICE REPORT

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• Doxycycline, Demeclocycline (photosensitivity most common than with any other tetracyclines) Antibiotics that Pts should avoid sunlight
• Flucloxacillin: Cholestatic jaundice and hepatitis
• Co-amoxiclav: cholestatic jaundice
• Ethambutol – visual effects
• Linezolid: blood disorders and optic neuropathy
• Co-trimoxazole: Steven Johnson syndrome
• Quinolones : tendon damage, arthropathy (joint problems) in children and possible convulsions (with NSAIDS). AOERTIC

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ANTI-BIOTIC THERAPY

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GENITAL . SYSTEM . INFECTIONS

• Bacterial vaginosis – oral metronidazole, clindamycin topical
• Chlamydia - ………………………….

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• Urinary Tract infection:
• Nitrofurantoin and Trimethoprim (can use amoxicillin, ampicillin, oral cephalosporin)
• Nitrofurantoin – Avoid if Egfr is less than 45ml/min. see new changes.
• 3 days treatment for women and 7 days for men and pregnant women.
• NEONATAL HAEMOLYSIS IF USED AT TERM
•  G6PD DEFICIENCY

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NITROFURANTOIN

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• renal Impairment changes

In adults:

• Avoid if eGFR less than 45 mL/ minute/1.73 m2; may be used with caution if eGFR 30–44 mL/ minute/1.73 m2 as a short-course only (3 to 7 days), to treat uncomplicated lower urinary-tract infection caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk.

In children:

• Avoid if estimated glomerular filtration rate less than 45 mL/minute/1.73 m 2; may be used with caution if estimated glomerular filtration rate 30–44 mL/ minute/1.73 m2 as a short-course only (3 to 7 days), to treat uncomplicated lower urinary-tract infection caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk.

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ANTI-BIOTIC THERAPY

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G. I. INFECTIONS

• Campylobacter

clarithromycin or ciprofloxacin

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• Salmonella – ciprofloxacin

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• Gastro- enteritis - SELF LIMITING

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• Shigellosis - ciprofloxacin

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• E.COLI – ciprofloxacin

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NOSE INFECTIONS �

NOSE INFECTIONS

INUSITIS ………NOSE INFECTIONS

• SINUSITIS treatment
• RX
• PHENOXYMETHYLPENICILLIN
• CO-AMOXICLAV

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• DOXYCYCLINE OR CLARITHROMYCIN IF ALLERGIC TO PENICLLIN

ANTI-BIOTIC THERAPY – BACTERIAL MENINGITIS

• Meningitis – initial empirical therapy
• Transfer patients to hospital immediately
• with non-blanching rash , Give Benzylpenicillin before transfer to hospital if appropriate.
• Cefotaxime – alternative
• Chloramphenicol – alternative
• Dexamethasone (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery.

MENINGITIS: IF AETIOLOGY IS UNKNOWN

• In hospital, if aetiology unknown:
• Adult and child 3 months–59 years, cefotaxime (or ceftriaxone)
• Consider adding vancomycin if prolonged or multiple use of other antibacterials in the last 3 months, or if travelled, in the last 3 months, to areas outside the UK with highly penicillin- and cephalosporin-resistant pneumococci.
• Suggested duration of treatment at least 10 days
• Adult aged 60 years and over cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)
• Consider adding vancomycin if prolonged or multiple use of other antibacterials in the last 3 months, or if travelled, in the last 3 months, to areas outside the UK with highly penicillin- and cephalosporin-resistant pneumococci.
• Suggested duration of treatment at least 10 days

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ANTI-BIOTIC THERAPY – RESPIRATORY SYSTEM

RESPIRATORY SYSTEM INFECTIONS

• COMMUNITY -ACQUIRED PNEUMONIA –(LOW-SEVERITY)
• Amoxicillin
• COMMUNITY -ACQUIRED PNEUMONIA (MODERATE)

AMOXICILLIN

• COMMUNITY -ACQUIRED PNEUMONIA (HIGH)
• CO-AMOXICLAV with clarithromycin
• …..2^nd levofloxacin

• HOSPITAL-ACQUIRED PNEUMONIA – OVER 48 hours
• …EARLY ONSET/ non severe – CO-AMOXICLAV
• …LATE ONSET / severe– higher risk of resistance
• PIPERACILLIN AND TAZOBACTAM IV .

ANTI-BIOTIC THERAPY

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BLOOD INFECTIONS

What are the symptoms of sepsis ???

• Septicaemia hospital acquired ------- piperacillin and tazobactam
• Septicaemia community acquired –----- piperacillin and tazobactam
• Septicaemia related to vascular catheter - ----- vancomycin

EAR INFECTIONS

• OTITIS EXTERNA – First Line – Spray or FLUCLOXACILLIN , Second Line - clarithromycin
• OTITIS MEDIA – FL - AMOXICILLIN SL – COAMOXICLAV / CLARITHROMYCIN

EYE INFECTIONS

• CONJUCTIVITIS – Chloramphenicol or fusidic acid eye drops

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ANTI-BIOTIC THERAPY

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SKIN INFECTIONS

• Diabetic foot ulcer- mild and severe cases – flucloxacillin
• Impetigo – bolus and non-bolus
• Cellulitis / Erysipelas/ Animal scratches/ insect bite- Flucloxacillin, clarithromycin or doxycycline
• Animal and Human bites – Co-amoxiclav, Doxycycline+ METRONIDAZOLE
• Mastitis – FLUCLOXACILLIN /// Erithromycin 10 to 14 days

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QUESTION 6

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Miss. B is 7 years old and was brought to the pharmacy with spots that are dome shaped, sometimes itchy but not painful on her armpit.

What is the most inappropriate advice to be given to Miss B?

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A. the infection usually clears up on its own.

B. the infection does not normally cause any symptoms other than the spots

C. the infection does not usually interfere with everyday activities, such as going to work, swimming or playing sports.

D. It's not necessary to stay away from work, school or nursery.

E. It is a bacterial infection that affects the skin.

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C-DIFF

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Some antibiotics cause C.Diff infection as a side-effect.

• Examples include –
• CO-Amoxiclav, Clindamycin, Cephalosporins (2^nd & 3^rd generation), Ampilcillin, Amoxicillin, Quinolones

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TREAT WITH

New change in BNF Jan 2022

• VANCOMYCIN or FIDAXOMICIN Orally
• only if first choice not available - metronidazole

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QUICK KEY POINTS

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Colourful urine:

• Rifampicin ---- Orange/brown urine
• Nitrofurantoin------ yellow/brown urine
• METRONIDAZOLE - DARK
• Trimethoprim, Co-trimoxazole – CAUSE Blood disorders (sore throat, fever, malaise, rash, mouth ulcers, bruising and bleeding)
• Vancomycin can cause ………….. Syndrome?

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RED MAN SYNDROME

Aminoglycosides

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• narrow therapeutic index
• SUMMARY
• They are not absorbed from the gut although its possible in IBD/Liver disease
• Loading dose may be calculated based on patient’s weight or renal function.
• ONCE daily administration is preferred to multiple-daily dose regimens except in patients with endocarditis due to gram+ bacteria.
• Monitor serum concentration to prevent excessive and sub-therapeutic concentrations – narrow therapeutic index
• PREGNANCY

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IDEAL BODY WEIGHT

Aminoglycosides

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Side – effects

• Ototoxicity
• Nephrotoxicity
• Skin reactions
• histamine related adverse reactions – gentamicin
• NB– Naseptin cream contains peanut oil . Check allergy!!
• TROUGH AND PEAK
• learn gentamicin and amikacin

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VANCOMYCIN

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• PRE – DOSE TROUGH LEVEL – 10 – 15mg
• Avoid in pregnancy
• Nephrotoxicity
• Ototoxicity
• Red mans syndrome
• Skin disorders
• monitoring

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BETA LACTAM ANTIBIOTICS

CEPHALOSPORINS

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• BROAD SPECTRUM
• Learn examples of cephalosporin generations
• The principal side-effect of cephalosporins is hypersensitivity.
• About 0.5% - 6.5% of penicillin-sensitive patients will also be allergic to CEPHALOSPORINS
• False positive urinary glucose test
• Also used to treat UTI, soft tissue infections e.g. cellulitis, abscess

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METRONIDAZOLE

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SUMMARY POINTS on metronidazole

• Metronidazole is active against anaerobic bacteria.
• Metronidazole should be taken with or after food.
• Metronidazole interacts with warfarin, alcohol – avoid + 48 hrs after
• Disulfiram –like reaction can occur with alcohol
• Metronidazole can turn urine colour dark

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MACROLIDES

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• Mechanism - Inhibit bacterial protein synthesis.
• are enzyme inhibitors NB drug Interaction………………..
• can cause ototoxicity in high doses
• QT prolongation – NB drug Interaction………………..
• Azithromycin 1g,500mg, 500mg used to treat chlymidia
• Good alternative if patient is allergic to penicillin.
• New change – intrx with hydroxychloroquine and chloroquine to cause cardiovascular events

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TETRACYCLINES

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• SUMMARY
• Tetracyclines are broad-spectrum antibiotics
• Tetracyclines are photosensitive
• Can cause teeth discolouration – should not be give to children under 12 years
• Headache and visual disturbances may indicate benign intracranial hypertension.
• Tongue and tear discolouration can occur with minocycline .
• minocycline can cause lupus and irreversible pigmentation . Pg 609
• Do not give to pregnant women .and breastfeeding.

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DOGS LIKE MILK- DOXYCYCLINE , LYMECYCLINE, MINOCYCLINE

QUINOLONES

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• See MHRA and CHM safety information on the use of systematic and inhaled fluoroquinolones. BNF 82
• The CSM has warned that quinolones may induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them. Discontinue if psychiatric, neurological or hypersensitivity reactions (including severe rash) occur. 
• risk of tendon damage
• quinolones are contra-indicated in patients with a history of tendon disorders related to quinolone use
• patients over 60 years of age are more prone to tendon damage
• the risk of tendon damage is increased by the concomitant use of corticosteroids
• if tendinitis is suspected, the quinolone should be discontinued immediately.

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QUINOLONES

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• Learn drug interactions associated with quinolones
• QT prolongation
• ANTACIDS?
• WARFARIN, Methotrexate, NSAIDS, steroids
• may affect blood glucose
• May affect growth in children
• visual disorders

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CLINDAMYCIN – KEY POINTS

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• Clindamycin is well concentrated in bone and excreted in bile and urine.
• gram+cocci, bacteroides fragilis, penicillin resistant staphlococci
• Skin reactions are very common
• Clindamycin has been associated with antibiotic –associated colitis.
• if treatment exceeds 10 days. Monitor liver and renal function
• warn patients and carers - Discontinue if diarrhoea occurs especially prolonged, severe or bloody.

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PENICILLIN

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• Inhibit bacterial cell wall synthesis by preventing peptidoglycan cross-linking
• Penicillin resistance can be cause by beta-lactamase bacteria.
• Some people have an allergy to penicillin.
• Up to 10% of patients report allergy but Less than 1 percent of people are dangerously allergic to penicillin
• Cross-sensitivity - Patients with a history of immediate hypersensitivity to penicillin may also react to the cephalosporins and other beta-lactam antibiotics, they should not receive these antibiotics.
• Amoxicillin is safe in pregnant and breast-feeding patients.
• Glandular fever ,
• rare side effect Amoxicillin – black hairy tongue

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PENICILLIN

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• Learn doses for common penicillins in children.
• broad-spectrum penicillins, can cause antibiotic-associated colitis. C.diff
• Penicillins can interact with methotrexate
• Flucloxacillin can cause liver impairment if used for more than 2 weeks
• Ampilcilin absorption can be reduced by the presence of food
• Benzylpenicillin sodium is inactivated by bacterial beta-lactamases – used to treat ……….. Caution in hypertension due to sodium content.

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FUNGAL INFECTIONS

KEY POINTS

• ORAL THRUSH
• VAGINAL THRUSH
• TINEA CORPORIS
• TINEA CRURIS
• TINEA PEDIS
• TINEA CAPITIS
• FUNGAL NAIL INFECTION – ONYCHOMYCOSIS

FUNGAL INFECTIONS

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• ORAL THRUSH – Miconazole , Nystatin
• VAGINAL THRUSH – Fluconazole, Clotrimazole
• TINEA CORPORIS – Miconazole, clotrimazole , Terbinafine cream ( continue for 7- 10 days after symptoms disappear)
• TINEA CRURIS a.k.a jock itch – Miconazole or clotrimazole
• TINEA PEDIS - Miconazole, clotrimazole , Terbinafine
• TINEA CAPITIS – Ketoconazole ( can cause liver problems if given orally)
• FUNGAL NAIL INFECTION – ONYCHOMYCOSIS – Amorolfine – refer if more than 2 nails affected .
• SERIOUS FUNGAL INFECTIONS –AMPHOTERICIN B- Nephrotoxic, stick to same brand

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MALARIA PROPHYLAXIS

LIFE-STYLE ADVICE

• Reduce time spent outdoors in the evening/night.
• long sleeves and trousers worn after dusk.
• Mosquito nets impregnated with permethrin, mats with vaporised insecticides.
• Diethyltoluamide (DEET) 20–50% formulations is safe and effective when applied to the skin of adults and children over 2 months of age. It can also be used with caution during pregnancy and breast-feeding. DEET reduces the SPF of sunscreen, so a sunscreen of SPF 30-50 should be applied, DEET should be applied after the sunscreen.

MALARIA PROPHYLAXIS

THERAPY

• Mefloquine - ……………………….
• Atovaquone and proguanil - …………….
• Doxycycline – ……………………
• Epilepsy, ADHD - Chloroquine and mefloquine are unsuitable due to neuropsychiatric reactions
• Anticoagulants - Travellers taking warfarin should begin chemoprophylaxis 2–3 weeks before departure; INR should be stable before departure, and should be measured before starting chemoprophylaxis, 7 days after starting, and after completing the course.
• Asplenia - Increased risk of severe malaria, need to be extra cautious against contracting malaria
• Pregnancy - …………………………

THE END

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